Before you take your first class, we ask that you complete some brief health information, so that we can know if you have any special needs. If you are over 69 years of age and/or you are not used to being active, check with your doctor.

Do you have any physical or mental disabilities or challenges that might affect your exercising? *

Yes

No

Through your own experience or a doctor's advice, is there any reason you shouldn't exercise? *

Yes

No

If you answered YES to one or more questions, you should consult your doctor before becoming more physically active.

Do you have any injuries that you would like to disclose? *

Yes

No

If you answered yes, please explain.

WAIVER/RELEASE OF LIABILITY

In consideration of your acceptance of this form, I for myself, my heirs, executors, administrators and assigns, forever waive, release and discharge any and all rights, claims for damages, unknown, that I may have against ONE WITH HEART, their employees, members, or instructors, for any and all injuries in any manner arising or resulting from my participation in classes. I attest and verify that I have full knowledge of the risks involved in any martial arts, weights, exercise, and fitness programs and that I freely and voluntarily assume those risks as incident to participation, and that I will assume and pay my own medical and emergency expenses in the event of accident, illness, or other incapacity, regardless of whether I have authorized such expenses, and that I am medically and physically fit and able to participate in classes. I also give consent to ONE WITH HEART, its owner, teachers, employees, and other students to give minor emergency first aid and/or advice to me. I hereby release claims I have towards them for giving me such treatment. All dues and payments for classes are nonrefundable and non-transferable. I give ONE WITH HEART permission to use any photos/videos taken of me for publicity.

Participants Signature *

Parent or Legal Guardian Signature (If under 18 years old)

How did you hear about us? (Facebook, Google, Yelp, Etc) *

If you were referred, who can we thank?

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